Jornal Brasileiro de Nefrologia · Nov 9, 2026

IgA nephropathy: evolving treatment strategies

By Mastroianni-Kirsztajn G, Siliano JM, Luciano EP

IgA nephropathy (IgAN) is the most common primary glomerular disease and is characterized by marked clinical, laboratory, and histopathological heterogeneity, with a variable risk of progression to advanced stages of chronic kidney disease depending on several underlying factors. A better understanding of its pathogenesis, which involves at least a four-hit pathogenic sequence, has enabled the development of novel therapeutic strategies targeting different stages of disease development, including agents directed at specific molecular pathways. Supportive kidney-protective therapy is now well established as the cornerstone of IgAN management and involves lifestyle modifications such as a healthy diet, regular physical activity, weight control, smoking cessation, sodium restriction, optimal blood pressure control, and interventions to reduce cardiovascular risk. Pharmacological measures include renin-angiotensin-aldosterone system and sodium-glucose cotransporter 2 (SGLT2) inhibitors, as well as mineralocorticoid receptor and endothelin A receptor antagonists. Historically, immunosuppressive treatment relied primarily on systemic corticosteroids, with cyclophosphamide or azathioprine reserved for selected clinical situations. More recently, targeted-release budesonide has emerged as a therapeutic option, followed by the development of agents directed at specific molecular pathways, particularly complement inhibitors and therapies targeting BAFF and/or APRIL signaling, among others. Although this expanding therapeutic armamentarium provides new opportunities to improve patient outcomes, it also introduces uncertainty and complexity into clinical decision-making. Therefore, defining evidence-based parameters to guide the selection and combination of available therapies according to the distinct endotypes of IgAN has become increasingly important.

doi.org/10.1590/2175-8239-jbn-2026-0279enOpen accessPubMed 43002663Interventions